Cathy Alessi

VA Greater Los Angeles Healthcare System, Los Ángeles, California, United States

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Publications (90)374.8 Total impact

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    ABSTRACT: AbstractObjective
    03/2015; 1(1-1):40-43. DOI:10.1016/j.sleh.2014.12.010
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    ABSTRACT: Epidemiologic studies have shown that approximately 50% of older adults have sleep problems, many of which carry deleterious consequences that affect physical and mental health and also social functioning. However, sleep problems in late life are often unrecognized, and are inadequately treated in clinical practice. This article focuses on the diagnosis and treatment of the 2 most common sleep problems in older patients: sleep apnea and insomnia. Copyright © 2015 Elsevier Inc. All rights reserved.
    Medical Clinics of North America 03/2015; 99(2):431-439. DOI:10.1016/j.mcna.2014.11.013 · 2.80 Impact Factor
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    ABSTRACT: A growing number of positive airway pressure (PAP) device users will develop physical/sensory impairments such as arthritis. For these individuals, the usability of their PAP devices (eg, efficiency and satisfaction) may impact the frequency and safety of device usage. Questionnaires to assess PAP usability are unavailable; therefore, we developed the Usability of Sleep Apnea Equipment - Positive Airway Pressure (USE-PAP) questionnaire. Questionnaire development included in-depth interviews to identify relevant content areas, a technical advisory panel to review/edit items, cognitive interviews to refine items, and a cross-sectional survey of Veterans Affairs sleep clinic patients assessing PAP device usability overall (one multi-item scale), usability of PAP components (multi-item scales for machine controls, mask/headgear, tubing, and humidifier), frequency of usability-related issues (one multi-item scale), PAP device characteristics, and demographics. After conducting 19 in-depth interviews, a panel meeting, and 10 cognitive interviews, we administered the survey to 100 PAP device users (67% ≥60 years; 90% male). The items assessing machine control usability received the least favorable ratings. Twenty percent of respondents reported difficulty getting equipment ready for use, and 33 percent had difficulty cleaning equipment. The six multi-item scales had excellent internal consistency reliability (alpha ≥0.84) and item-rest correlations (≥0.39). This study provides initial support for the USE-PAP for measuring PAP device usability. Studies that include large samples are needed to further evaluate the psychometric properties of the USE-PAP. In addition, comparisons of USE-PAP responses with direct observations of PAP-related tasks and objectively measured PAP adherence are needed to fully evaluate the questionnaire. Published by Elsevier B.V.
    Sleep Medicine 02/2015; 16(5). DOI:10.1016/j.sleep.2015.01.019 · 3.10 Impact Factor
  • Cathy Alessi, Michael V Vitiello
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    ABSTRACT: Up to 40% of older adults have insomnia, with difficulty getting to sleep, early waking, or feeling unrefreshed on waking. The prevalence of insomnia increases with age. Other risk factors include psychological factors, stress, daytime napping, and hyperarousal. We conducted a systematic review and aimed to answer the following clinical question: What are the effects of non-drug treatments for primary insomnia in older people (aged 60 years and older)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We found 14 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. In this systematic review, we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy for insomnia (CBT-I), exercise programmes, and timed exposure to bright light.
    Clinical evidence 01/2015; 2015.
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    ABSTRACT: Study Objectives: The impact of hospitalization on sleep in late-life is underexplored. The current study examined patterns of sleep quality before, during, and following hospitalization, investigated predictors of sleep quality patterns, and examined predictors of classification discordance between two suggested clinical cutoffs used to demarcate poor/good sleep. Methods: This study included older adults (n = 163; mean age 79.7 +/- 6.9 years, 31% female) undergoing inpatient post-acute rehabilitation. Upon admission to inpatient postacute rehabilitation, patients completed the Pittsburgh Sleep Quality Index (PSQI) retrospectively regarding their sleep prior to hospitalization. They subsequently completed the PSQI at discharge, and 3 months, 6 months, 9 months, and 1 year post discharge. Patient demographic and clinical characteristics (pain, depression, cognition, comorbidity) were collected upon admission. Results: Using latent class analysis methods, older adults could be classified into (1) Consistently Good Sleepers and (2) Chronically Poor Sleepers based on patterns of self-reported sleep quality pre-illness, during, and up to 1 year following inpatient rehabilitation. This pattern was maintained regardless of the clinical cutoff employed (> 5 or > 8). Logistic regression analyses indicated that higher pain and depressive symptoms were consistently associated with an increased likelihood of being classified as a chronic poor sleeper. While there was substantial classifi cation discordance based on clinical cutoff employed, no significant predictors of this discordance emerged. Conclusions: Clinicians should exercise caution in assessing sleep quality in inpatient settings. Alterations in the cutoffs employed may result in discordant clinical classifi cations of older adults. Pain and depression warrant detailed considerations when working with older adults on inpatient units when poor sleep is a concern.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 10/2014; 11(1). DOI:10.5664/jcsm.4362 · 2.83 Impact Factor
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    ABSTRACT: Background Evidence suggests that medical equipment often fails to accommodate the needs of individuals with disabling conditions. Few studies have focused on the accessibility of home medical devices such as positive airway pressure (PAP), which is a type of home medical equipment prescribed for long-term therapy. Objective The purpose of this study was to explore in detail the types of difficulties experienced by patients with physical/sensory impairments who use PAP devices, as an initial step in designing a questionnaire to survey users about this topic. Methods In this descriptive study, in-depth interviews were conducted with 19 participants (9 patients with physical/sensory impairment and 10 healthcare providers). Interviews were coded and analyzed for major topics. Results Participants detailed the numerous ways in which current PAP devices fail to meet the needs of individuals with physical/sensory impairments (e.g., tremor, poor depth perception, paresis), by requiring patients to perform manually difficult tasks, such as inserting PAP parts through small apertures, attaching parts using a twisting motion, and lifting arms overhead to apply PAP headgear. These demands contributed to patients’ frustration with and reduced usage of the home medical device. Conclusions Our findings suggest that home medical devices such as PAP may not be currently designed to meet the needs of some users with physical/sensory impairments. Additional studies are needed to measure the prevalence and impact of impairment-related barriers on PAP adherence for this common medical equipment.
    Disability and Health Journal 06/2014; DOI:10.1016/j.dhjo.2014.06.002 · 1.50 Impact Factor
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    ABSTRACT: Objectives To examine the relationship between changes in objectively assessed sleep and global cognitive functioning from inpatient postacute rehabilitation to 6-month follow-up. DesignSecondary analysis of two prospective, longitudinal studies. SettingInpatient rehabilitation units at a Veterans Affairs Medical Center. ParticipantsOlder adults (mean age 73.8 ± 9.4) undergoing inpatient rehabilitation (n = 192). MeasurementsAll participants completed 7 nights and days of ambulatory sleep monitoring using wrist actigraphy (yielding an estimate of nighttime wakefulness and daytime sleep) and the Mini-Mental State Examination (MMSE) during a postacute inpatient rehabilitation stay and 6 months after discharge. The 5-item Geriatric Depression Scale, Geriatric Pain Measure, and Cumulative Illness Rating Scale for Geriatrics were completed during inpatient rehabilitation. ResultsGrowth curve modeling (controlling for baseline age, education, sex, body mass index, depression, pain, and comorbidity burden) revealed that individuals whose amount of daytime sleep decreased from inpatient postacute rehabilitation to 6-month follow-up also experienced improvements in MMSE score (β= −0.01, t(80 = −3.22, P = .002)). Change in nighttime wakefulness was not a significant predictor of change in MMSE score. Conclusion Older adults whose daytime sleeping decreased after hospital discharge also experienced improvements in cognitive functioning at 6 month follow-up. As such, daytime sleep may represent a promising candidate for targeted interventions aimed at promoting cognitive recovery after hospital discharge.
    Journal of the American Geriatrics Society 01/2014; 62(1). DOI:10.1111/jgs.12622 · 4.22 Impact Factor
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    ABSTRACT: Sleep quality is related to emotional, physical, psychological and cognitive functioning and functional independence in later life. After acute health events, older adults are likely to utilize postacute rehabilitation services to improve functioning and facilitate return to independent living. Patterns of how sleep changes with postacute rehabilitation, and predictors of such patterns, are unknown. The current investigation employed latent class analysis (LCA) methods to classify older adults (n = 233) into groups based on patterns of self-reported sleep quality pre-illness, during postacute rehabilitation and up to 1 year following postacute rehabilitation. Using LCA, older adults were grouped into (1) consistently good sleepers (46%), (2) good sleepers who transitioned into poor sleepers (34%), (3) consistently poor sleepers (14%) and (4) poor sleepers who transitioned into good sleepers (6%). In three planned analyses, pain was an independent predictor of membership in classes 1 or 2 (good pre-illness sleep quality) versus classes 3 or 4 (poor pre-illness sleep quality), and of membership in class 1 (consistently good sleep) versus class 2 (good sleep that transitioned to poor sleep). A lower Mini-Mental State Examination score was a predictor of membership in class 1 versus class 2. There were no statistically significant predictors of membership in class 3 versus class 4. Demographics, comorbidities and depressive symptoms were not significant predictors of class membership. These findings have implications for identification of older adults at risk for developing poor sleep associated with changes in health and postacute rehabilitation. The findings also suggest that pain symptoms should be targeted to improve sleep during postacute rehabilitation.
    Journal of Sleep Research 07/2013; DOI:10.1111/jsr.12066 · 2.95 Impact Factor
  • Cathy Alessi, Michael V Vitiello
    American family physician 02/2013; 87(4):280-1. · 1.82 Impact Factor
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    ABSTRACT: To determine the prevalence of occult sleep disordered breathing (SDB) and describe the relationship between classic SDB symptoms (e.g., loud snoring) and occult SDB in older veterans with insomnia. We analyzed baseline survey and in-home sleep study data for 435 veterans (mean age = 72.0 years [SD 8.0]) who had no known history of SDB, met International Classification of Sleep Disorders 2(nd) Edition criteria for insomnia, and were enrolled in a behavioral intervention trial for insomnia. Variables of interest included apnea-hypopnea index (AHI) ≥ 15, age, race/ethnicity, marital status, body mass index (BMI), insomnia subtype (i.e., onset, maintenance, or terminal), self-reported excessive daytime sleepiness, snoring, and witnessed breathing pause items from the Berlin Questionnaire. We computed the frequency of AHI ≥ 15 and assessed whether each classic SDB symptom was associated with an AHI ≥ 15 in 4 separate multivariate logistic regression models. Prevalence of AHI ≥ 15 was 46.7%. Excessive daytime sleepiness (adjusted odds ratio 1.63, 95% CI 1.02, 2.60, p = 0.04), but not snoring loudness, snoring frequency, or witnessed breathing pauses was associated with occult SDB (AHI ≥ 15). Insomnia subtypes were not significantly associated with occult SDB (p > 0.38). In our sample of older veterans with insomnia, nearly half had occult SDB, which was characterized by reported excessive daytime sleepiness, but not loud or frequent snoring or witnessed breathing pauses. Insomnia subtype was unrelated to the presence of occult SDB. Fung CH; Martin JL; Dzierzewski JM; Jouldjian S; Josephson K; Park M; Alessi C. Prevalence and symptoms of occult sleep disordered breathing among older veterans with insomnia. J Clin Sleep Med 2013;9(11):1173-1178.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 01/2013; 9(11):1173-8. DOI:10.5664/jcsm.3162 · 2.83 Impact Factor
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    ABSTRACT: PURPOSE: Little is known about the ease of use of positive airway pressure (PAP) equipment and whether PAP equipment usability is associated with adherence. This pilot project aims to determine whether perceived difficulty with the mechanics of using PAP equipment is associated with nonadherence. METHODS: Within a larger study of insomnia treatments, we screened (via telephone interview) 148 adults for sleep apnea/prior PAP use and asked them to describe the degree of difficulty putting on their PAP mask, adjusting their mask straps, turning dials/pushing PAP machine buttons, disconnecting tubing, and removing the machine's water chamber (five items; five-point Likert-like scale) and to report their PAP use (0 versus ≥1 days in the past week). RESULTS: Mean age of participants was 66.7 years (SD 7.0). Thirty respondents (20.3 %) reported at least "some difficulty" with at least one aspect of PAP equipment usability, and 15 respondents (10.1 %) reported at least "quite a lot of difficulty" with one or more aspects of PAP equipment usability. Of the participants, 43.9 % reported not using PAP equipment at all during the past week. Participants (73.3 %) with substantial PAP equipment difficulty (at least quite a lot of difficulty) versus 40.6 % without substantial difficulty reported zero nights of PAP use in the past week (chi-square 5.86, p = .015). CONCLUSIONS: Difficulty using PAP equipment is associated with PAP nonadherence. Studies are needed to confirm these findings and to identify determinants of poor usability. If findings are confirmed, strategies could be developed to improve PAP usability, which may improve adherence.
    Sleep And Breathing 11/2012; 17(2). DOI:10.1007/s11325-012-0779-y · 2.87 Impact Factor
  • Jaime Hughes, Cathy A. Alessi, Jennifer L. Martin
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    ABSTRACT: Sleep is a modifiable health behavior critical to healthy aging, yet is rarely addressed in geriatric rehabilitation or chronic disease management programs. While questionnaires have been validated for self-reported assessment of sleep, many are not appropriate for frail older adults due to length and item complexity. In a larger study of sleep in VA Adult Day Health Care (ADHC), we screened 54 individuals (mean age=78, 94% male) for sleep complaints using qualitative feedback ("Tell me about your sleep.") and 4 items from the Pittsburgh Sleep Quality Index (minutes to fall asleep, minutes awake at night, hours of sleep, sleep quality). Qualitatively, 37 respondents (69%) indicated one or more sleep disturbances, most commonly trouble staying asleep (n=18), physical health problems interrupting sleep (n=13), trouble falling asleep (n=9), and sleep apnea (n=8). Quantitatively, many endorsed characteristics of clinically-defined insomnia: 28 (52%) respondents spent ≥30 minutes awake at night, 23 (43%) took ≥30 minutes to fall asleep, and 20 (37%) slept 6 hours or less. 12 (22%) endorsed "poor" sleep quality. Those who took ≥30 minutes to fall asleep were more likely to report one or more sleep problems on the qualitative item (X2=49.6, p=.002), but not to report trouble falling asleep, specifically (X2=2.6, p=.110). There were no other significant relationships among items. While ADHC participants frequently reported sleep-related difficulties, there are challenges to quantifying these complaints. Our findings highlight the need to develop appropriate methods to screen for sleep difficulties in this population and to identify those most appropriate for sleep interventions.
    140st APHA Annual Meeting and Exposition 2012; 10/2012
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    ABSTRACT: Background: Obstructive sleep apnea (OSA) is a costly, serious health condition involving cessations in breathing during sleep that leads to fragmented sleep and daytime sleepiness. Long-term consequences include heart disease, stroke, depression and cognitive impairment. For women, risk for OSA increases with age and after menopause (prevalence: 3.9% post-menopause vs. 0.6% pre-menopause) likely due to changes in hormones that protect against sleep apnea. However, OSA is often undiagnosed or misdiagnosed as hypothyroidism, depression, or insomnia. Modifying health behaviors that contribute to obesity can help reduce OSA risk. Objective and Methods: In a cross-sectional study of women Veterans with insomnia (mean age=49, 41% non-Hispanic White), we screened participants for OSA risk using the Berlin Sleep Apnea Questionnaire (BSAQ) and examined age and menopausal status as predictors of high OSA risk. We also compared health-related quality-of-life (SF-12 mental and physical scores) in high versus low OSA risk groups on the BSAQ. Results: 40% of participants were obese and 38% had been treated for hypertension. 57% (n=60) were deemed at "high sleep apnea risk." Risk was significantly higher for menopausal than pre-menopausal women (70% vs. 17%, X2=9.84, p=.002). Menopause was a significant predictor of apnea risk (X2=5.01, p=0.25), but age was not (X2=0.18, p=.669). Lower physical health-related quality-of-life was related to high risk (t=4.79, p<.001). Discussion: Menopausal status, but not age, predicted high OSA risk on the BSAQ. Since treating OSA can reduce health consequences and improve quality of life, post-menopausal women Veterans with sleep complaints should be routinely screened for OSA.
    140st APHA Annual Meeting and Exposition 2012; 10/2012
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    ABSTRACT: Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.
    Journal of the American Geriatrics Society 06/2012; 60(7):1347-56. DOI:10.1111/j.1532-5415.2012.04004.x · 4.22 Impact Factor
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    ABSTRACT: To explore the unique impact of poor sleep and symptoms of depression on sleep quality for up to 1 year after inpatient post-acute rehabilitation among older adults. Prospective longitudinal cohort study. Two inpatient post-acute rehabilitation facilities. A total of 245 individuals older than 65 years (mean age = 80 years, 38% women). None. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) during the post-acute care stay twice to evaluate pre-illness sleep quality and sleep quality during the post-acute care stay, and again at 3-, 6-, 9-, and 12-month follow-up. Demographics, symptoms of depression, cognitive functioning, and comorbidities were also assessed. Across time points, sleep was significantly disturbed for many individuals. Nested regression models predicting PSQI total score at 3, 6, 9, and 12 months showed that variables entered in Block 1 (age, gender, cognitive functioning, and comorbidities) were significant predictors of poor sleep at 6-month follow-up but not at 3-, 9-, or 12-month follow-up. Depression (Block 2) and pre-illness PSQI total score (Block 3) were significant predictors of PSQI total score at all follow-up time points. PSQI total score during post-acute care (Block 4) explained a significant proportion of variance only at the 3-month follow-up. This study confirms that chronic poor sleep is common among older adults during post-acute rehabilitation and resolution of sleep disturbance after acute health events may be a lengthy process. Our findings expand understanding of the role of depressive symptoms and preexisting sleep complaints in predicting poor sleep over time among these vulnerable older adults.
    The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 06/2012; 20(6):477-84. DOI:10.1097/JGP.0b013e31824877c1 · 3.52 Impact Factor
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    ABSTRACT: Women will account for 10% of the Veteran population by 2020, yet there has been little focus on sleep issues among women Veterans. In a descriptive study of 107 women Veterans with insomnia (mean age = 49 years, 44% non-Hispanic white), 55% had probable post traumatic stress disorder (PTSD) (total score ≥33). Probable PTSD was related to more severe self-reported sleep disruption and greater psychological distress. In a regression model, higher PTSD Checklist-Civilian (PCL-C) total score was a significant independent predictor of worse insomnia severity index score while other factors were not. Women Veterans preferred behavioral treatments over pharmacotherapy in general, and efforts to increase the availability of such treatments should be undertaken. Further research is needed to better understand the complex relationship between insomnia and PTSD among women Veterans.
    Behavioral Sleep Medicine 05/2012; DOI:10.1080/15402002.2012.683903 · 1.56 Impact Factor
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    ABSTRACT: To evaluate whether objectively and subjectively measured sleep disturbances persist among older adults in assisted living facilities (ALFs) and to identify predictors of sleep disturbance in this setting. Prospective, observational cohort study. A total of 121 residents, age ≥ 65 years, in 18 ALFs in the Los Angeles area. Objective (actigraphy) and subjective (Pittsburgh Sleep Quality Index) sleep measures were collected at baseline and 3- and 6-month follow-up. Predictors of baseline sleep disturbance tested in bivariate analyses and multiple regression models included demographics, Mini-Mental State Examination score, number of comorbidities, nighttime sedating medication use, functional status (activities of daily living; instrumental activities of daily living), restless legs syndrome, and sleep apnea risk. Objective and subjective sleep measures were similar at baseline and 3- and 6-month follow-up (objective nighttime total sleep [hours] 6.3, 6.5, and 6.4; objective nighttime percent sleep 77.2, 77.7, and 78.3; and Pittsburgh Sleep Quality Index total score 8.0, 7.8, and 7.7, respectively). The mean baseline nighttime percent sleep decreased by 2% for each additional unit increase in baseline comorbid conditions (measured as the number of conditions), and increased by 4.5% for each additional unit increase in baseline activities of daily living (measured as the number of activities of daily living), in a multiple regression model. In this study, we found that objectively and subjectively measured sleep disturbances are persistent among ALF residents and are related to a greater number of comorbidities and poorer functional status at baseline. Interventions are needed to improve sleep in this setting.
    The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 04/2012; 20(6):485-93. DOI:10.1097/JGP.0b013e318252e3e0 · 3.52 Impact Factor
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    ABSTRACT: A standardized method of assessing daytime drowsiness in frail nursing home residents has not been previously available. We present here the development and test characteristics of an instrument to measure daytime drowsiness in nursing home residents with cognitive and functional impairment, the Multiple Sleep Latency Test-Nursing Home (MSLT-NH). In a standardized manner, the resident is tested three times in one day (at 9 a.m., 11 a.m., and 1 p.m.) to measure the amount of time until the subject falls asleep. The average sleep latency (minutes to fall asleep) is the measure of interest. We tested the MSLT-NH in 95 residents from six community nursing homes in the Los Angeles area (82% of subjects were female; 81% were white, mean age was 86.6 years and mean score on the Mini-Mental State Examination [MMSE] was 9.4). Interrater reliability of the MSLT-NH was quite good (correlations between raters ranged from 0.98 to 0.99; all p values were <.0001). Validity was assessed by comparing MSLT-NH results to simultaneous wrist activity estimation of sleep, and by comparing MSLT-NH findings to results from nighttime sleep estimation by wrist actigraphy the night prior to MSLT-NH. The percent agreement between MSLT-NH and wrist actigraph ranged from 77% to 79% MSLT-NH results were significantly associated with peak duration of nighttime sleep episodes the night prior to testing. The MSLT-NH was also quite acceptable for use in the NH setting. In conclusion, we have developed a promising measure of daytime drowsiness in NH residents. Further testing will help establish whether this test is a clinically useful measure of daytime drowsiness from medications or other conditions in the NH setting.
    Journal of Clinical Geropsychology 04/2012; 6(4):315-323. DOI:10.1023/A:1009543014436
  • Cathy A Alessi, Michael V Vitiello
    The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry 04/2012; 20(6):457-9. DOI:10.1097/JGP.0b013e31825688e4 · 3.52 Impact Factor

Publication Stats

4k Citations
374.80 Total Impact Points

Institutions

  • 2005–2015
    • VA Greater Los Angeles Healthcare System
      • Geriatric Research Education and Clinical Center
      Los Ángeles, California, United States
  • 1997–2015
    • University of California, Los Angeles
      • • Department of Medicine
      • • Division of Geriatrics
      Los Ángeles, California, United States
  • 2012
    • University of California, San Diego
      • Department of Medicine
      San Diego, CA, United States
  • 2007–2011
    • California State University, Northridge
      • Department of Psychology
      Los Angeles, CA, United States
  • 2007–2008
    • Mayo Clinic - Rochester
      Rochester, Minnesota, United States
  • 2006
    • Mayo Foundation for Medical Education and Research
      • Division of Pulmonary and Critical Care Medicine
      Scottsdale, AZ, United States
    • CSU Mentor
      Long Beach, California, United States
  • 1994–1999
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
  • 1998
    • Soonchunhyang University
      Onyang, South Chungcheong, South Korea